BACKGROUND: Chronic kidney disease (CKD) is associated with an increased risk of cardiac events and death; however, underuse of guideline-recommended therapies is widespread. The extent to which hospital performance affects the care of patients with CKD and non-ST-segment elevation acute coronary syndromes (NSTE ACSs) is unknown. STUDY DESIGN: Observational cohort. SETTING & PARTICIPANTS: 81,374 patients with NSTE ACSs treated at 327 US hospitals. PREDICTOR: Hospital performance, measured by quartiles of composite adherence to American Heart Association class I guidelines for therapy acutely (aspirin, beta-blockers, clopidogrel, heparin, and glycoprotein IIb/IIIa inhibitors) and at discharge (aspirin, clopidogrel, angiotensin-converting enzyme inhibitors, and lipid-lowering agents) in eligible patients. OUTCOMES & MEASUREMENTS: Use of each American Heart Association class I acute and discharge therapy stratified by continuous estimated glomerular filtration rate (eGFR). Multivariable models were adjusted for demographics, clinical factors, and hospital features. RESULTS: Better-performing hospitals had lower prescribing rates for most therapies (5 of 9) with lower levels of kidney function, whereas lower-performing hospitals were more likely to have similar prescribing rates across the eGFR spectrum, suggesting that prescribing patterns at these hospitals were insensitive to differences in eGFR. LIMITATIONS: Observational design, selection bias of study cohort. CONCLUSION: Patients with lower levels of kidney function admitted with NSTE ACSs are less likely to receive evidence-based therapies. Treatment disparities related to CKD are most evident at top-performing hospitals.